title: Intra-articular botulinum toxin A as an adjunctive therapy for refractory joint pain in patients with rheumatoid arthritis receiving biologics: a report of two cases.
abstract: We report the use of intra-articular Botulinum toxin A in two RA patients with persistently painful monoarthritis in ankle/feet joints. Both patients had monarticular pain despite a good response of all other joints to a combination therapy that included anti-tumor necrosis factor therapy. Both patients had failed intra-articular corticosteroid injections and declined surgical options. After a single, "off-label", intra-articular injection of Botulinum toxin A into the right ankle (100 unit) and left first metatarsophalangeal joint (25 unit), respectively, pain and function improved significantly (> or =40%) in both patients. Durable response with improvement of pain and function lasting 15-18 months was noted (follow-up continuing). Ankle joint swelling resolved by 15 months and MTP joint swelling by one month. Intra-articular BoNT/A may be an additional therapeutic option in RA patients with persistent monoarthritis. A randomized study is underway to confirm these findings.
authors.affiliation: Minneapolis VA Medical Center & University of Minnesota, Minneapolis, MN, USA. jasvinder.md@gmail.com
authors.forename: Jasvinder A
authors.initials: JA
authors.lastname: Singh
authors.forename: Maren L
authors.initials: ML
authors.lastname: Mahowald
mesh_terms: D000277:Adjuvants, Pharmaceutic; D000843:Ankle Joint / Q000000981:diagnostic imaging / Q000503:physiopathology; D018726:Anti-Dyskinesia Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000503:physiopathology; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000627:therapeutic use*; D006304:Health Status; D006801:Humans; D007270:Injections, Intra-Articular; D008297:Male; D008683:Metatarsophalangeal Joint / Q000000981:diagnostic imaging / Q000503:physiopathology; D008875:Middle Aged; D010146:Pain / Q000188:drug therapy*; D010147:Pain Measurement; D011859:Radiography; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
chemical_list: D000277:Adjuvants, Pharmaceutic; D018726:Anti-Dyskinesia Agents; D019274:Botulinum Toxins, Type A